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Private Sector Accountable Care Organization Development: A Qualitative Study
Ann Scheck McAlearney, ScD; Brian Hilligoss, PhD; and Paula H. Song, PhD
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Private Sector Accountable Care Organization Development: A Qualitative Study

Ann Scheck McAlearney, ScD; Brian Hilligoss, PhD; and Paula H. Song, PhD
Private sector accountable care organization development has been motivated by perceived opportunities to improve quality, efficiency, and population health, and the belief that payment reform is inevitable.
One important limitation of this study was the small number of organizations involved. Given the time and energy constraints of qualitative studies, there are significant barriers to large-scale studies. Future work can include the development of surveys based on this research to explore and validate our findings in large samples. However, the ACOs included in our study are relatively mature, and their experience and perspectives provide important insights for newer ACOs that are considering entering the private market and assuming downside risk. Another possible limitation is that the ACOs in our study are likely to have experienced substantial changes from the time of our initial visits, given the rapid development of the ACO market. 

Future Work 

The private sector ACO market is developing rapidly. Recent estimates suggest that approximately half of the 600 ACOs identified in the United States are private sector ACOs.37 Given this rapid growth, future research should include larger-scale studies to explore the structural and financial arrangements in private sector ACOs that facilitate their development. Future studies should also focus on the performance and sustainability of the ACO model in this market. To date, approximately one-third of the ACOs participating in the Medicare Pioneer ACO program have withdrawn38; however, far less is known about exits within the private sector. 


This study is among the first to explore the development of ACOs in the private sector. We found that these ACOs developed under the belief that payment reform is inevitable and that they perceived that becoming an ACO would allow them to respond to anticipated policy changes that will impact the way healthcare is delivered and reimbursed. These ACOs were also motivated by the opportunity to increase quality of care and efficiency and to improve population health. Moreover, each organization’s prior experience with successfully managing risk was identified as a factor that prepared these ACOs to enter downside risk arrangements with confidence. Although private sector ACOs are still evolving, improving our understanding of the factors that have been important for more mature ACOs can help facilitate the development of less mature organizations that are beginning or evolving their ACO journeys.


The authors are extremely grateful to the organizations and informants who participated in this study, and to the members of our Project Advisory Team. They also thank their research team members who assisted at various stages of this project: Meredith Rosenthal, Julie Robbins, Daniel Walker, Jennifer Hefner, Daniel Gaines, Lindsey Sova, Kelsey Murray, Pamela Thompson, Pamela Beavers, Alexandra Moss, Megan Sinclair, Kendall Haas, Mary Frances Gardner, and Jessica Stewart. 

Author Affiliations: Department of Family Medicine, College of Medicine (ASM), and Division of Health Services Management and Policy, College of Public Health (ASM, BH), The Ohio State University, Columbus, OH; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (PHS), Chapel Hill, NC

Source of Funding: The Robert Wood Johnson Foundation funded this research; however, the study sponsor had no involvement in the collection, analysis, or interpretation of data; in the writing of this manuscript; or in the decision to submit the manuscript for publication.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (ASM, BH, PHS); acquisition of data (ASM, BH); analysis and interpretation of data (ASM, BH, PHS); drafting of the manuscript (ASM, PHS); critical revision of the manuscript for important intellectual content (ASM, BH, PHS); statistical analysis (N/A); provision of patients or study materials (N/A); obtaining funding (ASM, BH, PSH); administrative, technical, or logistic support (ASM, PSH); and supervision (ASM). 

Address Correspondence to: Ann Scheck McAlearney, ScD, MS, Department of Family Medicine, College of Medicine, The Ohio State University, 273 Northwood and High Bldg, 2231 North High St, Columbus, OH 43201. E-mail: 

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